AHA Policy Statement Impact of Smokeless Tobacco Products on Cardiovascular Disease: Implications for Policy, Prevention, and Treatment A Policy Statement From the American Heart Association

Various forms of smokeless tobacco (ST) products (snuff, chewing tobacco) are used by individuals of all ages. Over the past several years, US tobacco companies have expanded marketing and promotion of ST products. A major aim of this statement is to review and summarize the scientific evidence regarding ST product use and the potential cardiovascular risks associated with ST product use that can be used to inform policy related to tobacco control and strategies related to tobacco harm reduction. A specific policy question is whether ST products should be recommended to smokers instead of cigarettes to reduce the morbidity and mortality associated with smoking and/or as an approach to enhance smoking cessation. Although evidence is consistent with the suggestion that the cardiovascular risks are lower with ST products compared with cigarette smoking, ST products are not without harm. As reviewed in this statement, there is evidence that long-term ST product use may be associated with a modest risk of fatal myocardial infarction (MI) and fatal stroke, suggesting that ST product use may complicate or reduce the chance for survival after a MI or stroke. In addition, there is inadequate evidence to support the use of ST products as a smoking cessation strategy. Based on the findings reviewed in this statement, clinicians should continue to discourage use of all tobacco products and emphasize prevention of smoking initiation and smoking cessation as primary goals for tobacco control. In the United States, various forms of ST products (snuff, chewing tobacco) are used by individuals of all ages, including adolescents and young adults.1 Over the past several years, US cigarette companies have been purchasing companies that only previously sold ST products.2 Consequently, there has been a proliferation of ST products such as moist snuff and snus that are sold under cigarette brand names such as Marlboro and Camel.2 The latter has been accompanied by expanded promotion of ST products.2 In 2009, the US Congress passed the Family Smoking Prevention and Tobacco Control Act (Tobacco Control Act) authorizing the regulation of tobacco products, including ST products.3 Recently, the US Food and Drug Administration (FDA) issued a final regulation related to the Tobacco Control Act that became effective June 22, 2010, which prohibits the sale of cigarettes and ST products to individuals younger than 18 years of age. This federal regulation also specifies new requirements related to tobacco marketing (labeling, advertising, and promotion) (Table 1).3 As smoke-free air laws proliferate across the country, ST products have been marketed as a situational substitute (“pleasure for whenever”) for cigarette smoking when smoking is prohibited in public places.4 A major aim of this statement is to review and summarize the scientific evidence regarding ST product use and the